Avir At Madisonville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 1 of 3 residents (Resident #52) reviewed for privacy while receiving wound care. The facility failed to ensure the privacy of Resident #52 by not closing the door all the way or pulling a privacy curtain during wound care. This failure could place residents at risk of loss of privacy and dignity. Findings include: Record review of the undated Face Sheet for Resident #52 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure with Hypoxia (lungs cannot properly exchange gases causing abnormal levels of oxygen and carbon dioxide in the blood, causing difficulty breathing and can be fatal), Obesity Body Mass Index 70 or greater, adult, (morbid obesity which can lead to a range of health problems including heart disease, high blood pressure, breathing, difficulties), and need for assistance with personal care. Record review of the Optional State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #5) of 19 residents reviewed for care plans. The facility failed to ensure Resident #5's comprehensive care plan reflected a plan of care for her left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) with interventions for the care and treatment of her left-hand contracture. These failures could place residents at risk for not receiving appropriate care and treatment. Findings included: Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #27) reviewed for quality of care. The facility failed to provide wound care for Resident #27 using professional wound care standards and failed to follow the facility Validation Checklist Wound Care procedure. This failure could place residents at risk of improper wound management, deterioration in existing wounds, leading to infection and pain. Findings include: A) Record review of Resident #27's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses of non-pressure chronic ulcer of left heel and midfoot with necrosis (death of body tissue) of muscle, and Type 2 Diabetes Mellitus without complication (long term condition in which the body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1of 3 residents reviewed with limited range of motion (Resident #5), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #5 had interventions in place for her left- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This failure placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheters (Resident #9). The facility failed to ensure Resident #9 received care to prevent urinary tract infections when they placed her catheter tubing under her leg and failed to have a secure catheter device in place to prevent dislodgement of the catheter. These failures could place residents with external catheters at risk for urinary tract infections and traumatic removal of the urinary catheter. Findings included: Review of Resident #9's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses acute and chronic respiratory failure, morbid obesity, COPD (chronic lung disease) and CHF (heart failure). Review of Resident #9's quarterly MDS assessment dated [DATE] reflected she was assessed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #69) of six residents reviewed for pharmaceutical services. The facility failed to ensure MA F waited for Resident #69 to consume her morning medications on 04/08/2025 before leaving the resident's room and to administer medication. The facility further failed to ensure Resident #69 receive antibiotic medication for UTI on 04/08/2025 in PM. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings include: 1) Review of Resident # 69's face sheet, dated 04/10/2025, reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses urinary tract infection ( an infection in your urinary system), type 2 diabetes mellitus with ketoacidosis without coma ( a serious complication of diabetes where the body does not produce enough insulin, leading to a buildup of harmful acids in the blood), essential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 15 residents, (Resident # 27) observed for infection control practices. The facility failed to ensure LVN B used proper infection control procedures while proving wound care. This failure could place residents at risk for cross contamination and infection. Findings include: Record review of Resident #27's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses of non-pressure chronic ulcer of left heel and midfoot with necrosis (death of body tissue) of muscle, and Type 2 Diabetes Mellitus without complication (long term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 5 residents reviewed for immunizations. (Resident #5 and Resident #67) The facility failed to document, in Resident #5's and Resident #67's medical records, having had received education, whether by self or with responsible party, of the benefits and potential side effects of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents who were reviewed for immunizations. (Resident #5 and Resident #67) The facility failed to document, in Resident #5's and Resident #67's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: A) Review of Resident #5's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 9 residents (Residents #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9) of 12 residents reviewed for medication administration were free of significant medication errors. Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9 did not receive their evening medications scheduled in the evening (to be administered between 4:00pm and 6pm) on 05/01/24 and 05/07/24 as ordered by the physician, placing them at risk. These failures could place residents at risk for not receiving the intended therapeutic benefit of the medications. Findings included: Resident #1 Record review of the face sheet of Resident #1 dated 05/10/24 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses included Hypertension, Unsteadiness on feet, Lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation. interview and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 4 of 5 residents (Residents #1, # 2, # 3 and #4) reviewed for ADL care in that: A) Resident #1 was not provided with nail care. B) Resident #2 was not provided with nail care. C) Resident #3 was not provided with nail care. D) Resident #4 was not provided with brief changes and peri care. These failures could place residents at risk of skin breakdown, pain, infection, and loss of self-esteem. Findings included: A. Record review of the undated Face Sheet for Resident #1 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the undated Medical Diagnosis sheet for Resident #1 reflected he had a diagnosis of Cerebral Palsy (a congenital, present from birth, disorder of movement, muscle tone or posture due to abnormal brain development) dated 07/01/2019 and muscle weakness generalized dated 11/03/2020. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #56 and Resident #3) of 5 residents reviewed for infection control. 1. The facility failed to ensure LVN A performed hand hygiene during wound care for Resident #56. 2. The facility failed to ensure CNA B and RA C performed hand hygiene during incontinence care for Resident #3. Findings included: 1. Review of Resident #56's Face Sheet dated 02/29/24, reflected he was an [AGE] year-old male admitted on [DATE]. His diagnoses included Lupus. Review of Resident #56's Progress Notes written by LVN D reflected: 02/26/24 at 5:33 AM Note Text: CNA reported that resident had a wound on his right lower leg and the wound was bleeding. Assessment performed of the wound. Two abrasions, red in sight, and warm to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #30) of 5 residents reviewed for resident rights. The facility failed to honor Resident #30's choice to not take Mirtazapine (anti-depressant). This failure placed residents at risk for loss of dignity and self-worth. Findings included: Record review of Resident #30's annual MDS assessment, dated 12/24/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included depression and non-Alzheimer's dementia. Record review of Resident #30's Order Summary Report for February 2024 reflected: 12/15/23 Mirtazapine Tablet 7.5 mg , give 1 tablet by mouth one time a day. Review of Resident #30's Informed Consent for use of Psychotropic Medication revealed the consent for mirtazapine was signed by a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #26 ) reviewed for accidents. The facility failed to supervise Resident #26 while smoking. This failure could place residents who required supervision while smoking at risk for burns. The findings included: Review of Resident #26's annual MDS assessment, dated 11/29/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included non-Alzheimer's dementia. Review of Resident #26's Care Plan, dated 04/15/22, reflected she smoked. Her facility interventions included: Smoking assessment by the SW and smoking in designated areas only. Review of Resident #26's, Safe Smoking Assessment, documented by the DON, dated 02/01/24, reflected the resident required direct supervision while smoking. An observation and interview on 02/28/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance that is palatable, attractive, and at a safe and appetizing temperature for 1 (Resident #33) reviewed for food and nutrition services. The facility failed to ensure the pureed meal which consisted of steak patty with brown gravy, broccoli and cauliflower blend, au gratin potatoes, and roll were prepared in a way to preserve vitamins and taste by not following required measuring when adding thickener and water to the food items. This failure could place residents at risk of nutrition and hydration and negatively impact the recovery from, illness or injury. Findings included : During the test tray tasting, with the Dietary Manager present, on 02/28/24 at 12:39 AM, the food was mildly warm. The regular plate was palatable. No complaints or concerns were noted with the regular plate; however, the puree plate was not visually pleasing, and the taste of the food was void of flavor. The plate consisted of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's dry goods storage, was labeled and dated according to guidelines. These failures could place residents at risk for food-borne illnesses. Findings included: Observations on 02/27/24 from 09:10 AM to 09:21 AM in the facility's only kitchen reflected: Three opened cans of Baking Powder, dated 9/29 and there was no visible expiration date. Three 1-gallon container of Worcestershire sauce, dated 5/22 and there was no visible expiration date. One of the containers had been opened and had congealed sauce, which adhered to the inside of the container and dried sauce drip stain on the outside of the container. A plastic container labeled Baking Soda, dated 12/30 and there was no visible expiration date. The label on the lid had an aged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for personal hygiene, in that: The facility failed provide showers to Resident #1 in compliance with her shower schedule. This deficient practice could place residents who are dependent on staff for ADL care at risk of poor hygiene, grooming, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not elsewhere classified and multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure all allegations involving abuse and neglect were immediately reported no later than 24 hours after an allegation was made for 1 of 2 residents (Resident #1) reviewed for grievances, in that: The facility failed to report Resident #1's allegation of verbal abuse to the State Agency within 24 hours. Resident #1's family filed a grievance on 10/18/23 that stated Resident #1 told them that staff were not changing her wound dressing, her wound was worsening, and she would not ask staff for assistance because staff yelled at her when she asked. This deficient practice could place residents at risk of abuse or neglect. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective and person-centered care for the resident and met professional standards of quality care for 1 of 5 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #1. This deficient practice could place residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1. This deficient practice could place residents at risk of not having their individual care needs met or diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure the resident environment remains as free of accidents and hazards for one (1) of one facility resident transport van reviewed for accidents and hazards. The facility failed to ensure the facility resident transport van used for dialysis appointments was maintained properly for safety hazards that may result in an injury to a resident. The transport van overheated en route back to the facility, the starter needed to be replaced, and then the engine needed to be replaced. The resident transport van was used 3-4 times a week on average for appointments, activity outings, etc. This failure could place residents at risk of injuries, illness, and hospitalization. Findings included: On 10/25/2023 at 1:30 pm, LVN A stated the van broke down numerous times over the last two months. LVN A said the facility used a rental van to transport residents. LVN A stated this inconvenienced the residents resulting in missed appointments. On 10/25/2023 at 1:50 pm,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure that residents had comfortable and safe temperature levels for one of four halls (D hall) and the dining area. The facility failed to ensure the facility was maintained at a comfortable and safe temperature level and maintained a temperature range of 71 to 81°F, when the HVAC units for the dining area and D hall were not functioning and the temperatures in these areas were between 79 -85 degrees. This failure placed residents at risk for heat related illnesses and an uncomfortable environment leading to a decreased quality of life. Findings Included: On 8/22/23 at 10:50 am, the MTD director stated there had been a problem for about 2 weeks with the air-conditioning in the dining room. He stated they had the unit repaired back in July of 2023, but it stopped working about 2 weeks ago. He stated he had the repair techs out here last week on 8/18/23 and they diagnosed the problem and stated they would have to order parts. He stated the temperature in the dining room has exceeded 81 degrees at times. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) of one facility resident transport van reviewed for accidents and hazards. The facility failed to ensure the facility resident transport van was inspected yearly for safety hazards that may result in an injury to a resident. The resident transport van was used 3-4 times a week on average for appointments, activity outings, etc. This failure could place residents at risk of injuries, illness, and hospitalization. Findings included: On [DATE] at 12:20 pm, a resident that did not want to be identified, informed the surveyor that the tags and inspection were out on the facility van. The resident stated they had expired the end of July. On [DATE] at 1:14pm, the Business Office Manager stated she had received a notice from Texas DMV in mid-[DATE] that they were unable to renew the registration on the van because they required proof of insurance. The check that had been sent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to be administered in a manner that maintained the wellbeing of each resident when the administration did not take immediate action when the motor vehicle insurance lapsed for one (van #1) out of one resident transport van The facility administration failed to ensure that the vehicle insurance for the resident transport van was paid and insurance in place prior to using the van for resident transports. The resident transport van was used 3-4 times a week on average for dialysis appointments, doctor appointments, activity outings, etc. This failure placed residents at risk of not having necessary resources and services available to them during day-to-day operations and emergencies which could result in lack of care. Findings included: In an interview with the Business Office Manager on [DATE] at 1:14 pm she stated the facility tag renewal check had been returned in Mid-June due to missing proof of insurance. She stated the insurance card they had on file…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, for 1 of 1 facility resident transport van reviewed for insurance coverage. The facility failed to ensure the resident transport van was fully insured per state laws while being operated to transport residents to and from appointments and outings. The resident transport van was used 3-4 times a week on average for appointments, activity outings, etc. This failure could place residents at risk for injuries and hospitalizations from vehicle accidents that would not be covered under vehicle insurance. Findings Included: In an interview with the Business Office Manager on [DATE] at 1:14 pm she stated the facility tag renewal check had been returned in Mid-June due to missing proof of insurance. She stated the insurance card they had on file had expired [DATE]. She stated she informed the Regional [NAME] President (RVP) and the AR rep in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly thaw a pan of approximately 15 pork chops. 2. The facility failed to properly label food in one of two facilities refrigerators located in the kitchen. 3. The facility failed to ensure temperatures were monitored and logged in the white open front combined refrigerator and freezer and the open top white deep freezer in the kitchen. 4. The facility failed to ensure Dietary [NAME] B and Dietary Aide C properly sanitized their hands between tasks. These failures could place the residents at risk for health complications and foodborne illnesses. Findings included: 1. Observation of the kitchen on 12/27/2022 at 8:15 AM - 9:00 AM revealed approximately 15 partially frozen pork chops in a deep silver pan located in the sink with approximately 1-2 inches of water in the silver pan. The pork chops were being thawed for the lunch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 9 of 11 Residents (#57, #32, #9, #48, #30, #3, #34, #14 and #23) reviewed for meals. The facility failed to ensure Resident #57, #32, #9, #48, #30, #3, #34, #14 and #23 had appropriate utensils on their meal trays. This failure placed residents at risk for not having their needs and preferences met and a decreased quality of life. Findings included: Observation on 12/28/2022 between 11:50 PM- 12:30 PM Residents in the dining room and in their rooms did not have knives on their meal tray. Record review of Resident # 57's face sheet, dated 12/30/2022, revealed resident was a [AGE] year-old female admitted to facility on 11/14/2022 had diagnosis muscle weakness generalized (lack of muscle strength), moderate protein-calorie malnutrition (deficiency of energy, protein and micronutrients), resident had surgery on her teeth after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Resident #57 and Resident # 44) of three resident reviewed for behavioral services. 1. The facility failed to ensure Resident #57 continued to receive psychiatric services after admission to the facility after she reported to have depression and was assessed to have depression. 2. The facility failed to ensure Resident #44 who was diagnosed with schizophrenia, major depressive disorder, and delusional disorders received the care and services needed, after recommendation from psychiatric services for treatment one time per month for 12 months. These failures could place residents at risk for their mental and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure each resident received and the facility provided food that accommodates resident allergies, intolerances, and preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for eight (Resident #, 57, Resident #32, Resident #9, Resident #48, Resident #30, Resident #3, Resident #14, and Resident #34) of nine residents reviewed for resident food preferences. The facility failed to ensure Residents #57, #32, #9, #48, #3, #30, #14 and #34 received their preferred meal choice. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life. Findings include: 1. Record review of Resident # 57's face sheet dated 12/30/2022 revealed resident was a 57 -year-old female admitted to facility on 11/14/2022 had diagnosis muscle weakness generalized (lack of muscle strength), moderate protein-calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 4 of 12 residents (Resident #20, #3, #10, and #26) reviewed for infection control measures. 1. The facility failed to ensure LVN C followed standard precautions during wound care for Resident #20's stage 3 pressure ulcer to her sacrum. 2. The facility failed to ensure LVN C followed standard precautions during wound care for Resident #3's stage 3 pressure ulcer to her sacrum. 3. The facility failed to ensure LVN C followed standard precautions during wound care for Resident #10's two stage 3 pressure ulcers to buttocks. 4. The facility failed to ensure ADON followed standard infection control measures when assisting Resident #23 with meal assistance. These failures could place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to coordinate assessment with the pre admission screening and resident review ( PASARR) program under medicaid including referring a new admit resident with mental disorder for level II for one (Resident #57) of two residents reviewed for PASARR's. The facility failed to ensure Resident #57 continued to receive psychiatric services after admission to the facility after she reported to have depression and was assessed to have depression. These failures could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life. Findings included: 1. Record review of Resident # 57's face sheet dated 12/30/2022 revealed resident was a 57 -year-old female admitted to facility on 11/14/2022 and had diagnoses of bipolar disorder ( a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day to day tasks), adjustment disorder with mixed anxiety and depressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for 2 of 12 residents (Residents #46 and #17) reviewed for quality of care. The facility failed to ensure Residents #46 and #17's fingernails and toenails were trimmed and cleaned. This failure could place residents at risk of scratches, infections, and poor self-esteem. Findings included: Review of Resident #46's undated face sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Diffuse Traumatic Brain Injury (brain injury resulting from rapid head rotations of the brain) with loss of consciousness of unspecified duration, muscle weakness, lack of coordination, limitation of activities due to disability, Cognitive Communication Deficit (difficulty with thinking and how one uses language), Hyperlipidemia (high levels of fats in the blood), Intermittent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of twelve residents (Resident #6) reviewed for quality of care. The facility failed to ensure LVN C followed verbal orders from the RN Nurse Practitioner to administer an enema. This failure could place residents at risk of a decline in overall health. Findings included: Review of Resident #6's undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified Cerebral Infarction (brain stroke), Asthma (condition in which airways become inflamed, narrow and swell, produce extra mucus which makes it difficult to breathe), Type 2 Diabetes Mellitus (adult onset), muscle wasting and atrophy (thinning of muscle mass), Chronic Idiopathic Constipation (common functional bowel disorder with difficult, infrequent or incomplete defecation), Dysphagia (difficulty swallowing), Muscle weakness, and unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one resident (Resident #6) reviewed for respiratory care. The facility failed to ensure Resident #6's nebulizer mask and tubing were covered and dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: Review of Resident #6's undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified Cerebral Infarction (brain stroke), Asthma (condition in which airways become inflamed, narrow and swell, produce extra mucus which makes it difficult to breathe), Type 2 Diabetes Mellitus (adult onset), muscle wasting and atrophy (thinning of muscle mass), Chronic Idiopathic Constipation (common functional bowel disorder with difficult, infrequent or incomplete defecation), Dysphagia (difficulty swallowing), Muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medication regiment review was completed by the Medical Director for one (Resident # 57) of two residents reviewed for unnecessary medications. The facility failed to ensure the Medical Director followed up with his comment of continuing current order without a rationale for his response to the recommendation of the medication sedative/ hypnotic- duration- Sonata (Zaleplon). This failure could potentially place residents at risk of not having residents highest practicable level of physical, mental, psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy. Findings include: Record review of Resident # 57's face sheet dated 12/30/2022 revealed resident was a 57 -year-old female admitted to facility on 11/14/2022 and had diagnoses of bipolar disorder ( a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day to day tasks), adjustment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who used psychotropic drugs receive gradual dose reductions for one of three residents (Resident #3) reviewed for psychotropic medications. The facility failed to ensure Resident #3, who had a diagnosis of Ppsychotic Ddisorder with hallucinations, major depressive disorder, and anxiety disorder received GDRs for Buspirone, Clonazepam and Abilify. Thisese failures could affect all residents on psychoactive medications, by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #3's undated face sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (a group of lung disease that block airflow and make it difficult to breathe, Psychotic Disorder with Hallucinations (mental disorder characterized by disconnection from reality, hearing or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.